As they took control of both chambers of Congress and the White House in 2025, Republicans faced a dilemma. They wanted to extend the tax cuts enacted during Donald Trump’s first term, a central priority of both the president and the party’s corporate and donor base. But because the tax extensions would blow a multi-trillion-dollar hole in the ten-year deficit projection, they risked losing the votes of fiscal hawks inside their caucus. 

So, Republicans went hunting for “pay-fors” to lessen the deficit damage. They axed tax credits for EVs and clean energy and decimated funding for Medicaid and SNAP. But in addition to these well-publicized cuts, they radically reduced federal student loan subsidies, including those for graduate students.  

Of course, they didn’t say out loud that they were reducing support for graduate education to finance tax cuts to the wealthy and corporations. Instead, they and conservative think tanks argued for the cuts on other grounds. First, invoking the so-called Bennett Hypothesis—named after the former Education Secretary, William J. Bennett, who articulated the theory—they claimed that federal student aid enables colleges to raise tuition, and that cutting federal funding will therefore force tuition prices down. Second, channeling arguments made by pronatalists at places like the Heritage Foundation, they said that young people, especially women, spend too long in graduate school, delaying marriage and childbearing, and that shrinking higher-education subsidies will boost the fertility rate. 

These arguments point in opposite directions. The first claims that cutting federal loan support will make graduate education cheaper and therefore easier to earn, the other that those cuts will make grad school harder to pursue. Regardless, both converge on the same policy outcome: less federal money for graduate education, more for tax cuts.  

The One Big Beautiful Bill Act (OBBBA), which passed in July, reduces federal higher education spending by roughly $284 billion over a decade, according to the Congressional Budget Office, largely by tightening graduate student lending. It eliminates the Graduate PLUS program, which had allowed students to borrow up to the full cost of attendance for graduate degrees. Instead, the legislation limits future loan amounts based on the type of graduate program: $50,000 per year and $200,000 total for “professional” degrees, $20,500 per year and $100,000 total for all others.  

To avoid a political fight about which degrees count as “professional,” lawmakers added a snippet of ambiguous language from an otherwise unrelated regulation. They directed the Department of Education to clarify the final definitions based on it. In November, a committee empaneled by the department released those definitions as a first step in writing the regulations that will implement the new law. Medicine, dentistry, pharmacy, veterinary medicine, optometry, osteopathic medicine, podiatry, chiropractic, theology, law, and clinical psychology were deemed “professional” and eligible for higher federal loan limits. Nursing, teaching, social work, physical therapy, physician assistant programs, and audiology were not. 

Such regulatory notices usually fly under the public radar, but this one hit a nerve. Roughly four million nurses and more than two million social workers, including teachers and therapists, read the rule the same way: as a declaration that their work does not count as a profession. Their unions and trade associations protested. A prairie fire of anger and ridicule spread on social media. National media outlets covered the controversy. Even The Onion weighed in (“White House Reclassifies Nursing as a Hobby”). 

“None of us anticipated the offense that would be taken by the term ‘professional,’” a member of the department’s rulemaking committee told me. In retrospect, however, it’s not hard to understand the anger. Nursing and social work are overwhelmingly female professions already facing shortages, burnout, and stagnant pay. Getting a raise in these fields often requires a master’s degree, and the Trump administration was putting up roadblocks. Nurses already absorb abuse from hospital administrators and arrogant physicians while doing the unglamorous work of keeping patients alive. To then be downgraded—symbolically and financially—by the federal government was seen as disrespect. “It’s just a smack in the face,” said Susan Pratt, a nurse who is also president of a union representing nurses in Toledo, Ohio. “During the pandemic, the nurses showed up, and this is the thanks we get,” she told the AP.

Public outrage has been so intense that, in December, a bipartisan group of lawmakers asked the Education Department to restore nursing to the list of professional degrees.  

If the new federal graduate school loan regime is proving to be a disaster politically, it is not much better as policy. Robert Kelchen, a higher education policy professor at the University of Tennessee Knoxville (and data editor of the Washington Monthly college rankings), notes that loan limits only make sense if they follow outcomes—either to prevent students from taking on unsustainable debt or to discourage enrollment in programs with poor repayment prospects. By those metrics, nursing stands out for the opposite reason. It has strong debt-to-earnings ratios, strict licensing requirements, sustained labor-market demand, and a clear social return. If taxpayers are going to subsidize any graduate profession, nursing is among the safest investments. 

Capping graduate degree loans at $20,500 annually might sound reasonable to conservative lawmakers trying to fill a self-created budget hole, but it makes less sense if you’re a working nurse or physical therapist entering an expensive, clinically intensive program in a high-cost area without family wealth. Pair that cap with the elimination of Grad PLUS and a tighter income-driven repayment regime, and the math will not work for many prospective nurses and teachers. Some will never apply. Others will turn to private loans. Many will walk away. 

Of course, there are universities charging outrageously high tuition for certain graduate degrees that don’t lead to commensurately high incomes; some of those programs were created precisely to take advantage of unlimited federal graduate student loans. As the Washington Monthly reported in 2024, the worst offenders are often elite schools. For instance, Northwestern University offers a master’s in counseling that saddles average graduates with $153,657 in debt, who go on to earn only $56,897 on average annually five years later. (By comparison, many regional public universities offer the same degree at a fraction of the cost, and their graduates earn more.) Lawmakers could have protected grad students from such predatory programs—and taxpayers from picking up the tab when those students can’t repay the loans—by directing the Education Department to limit graduate loans based on the average earnings of specific degrees or programs. Instead, they rushed through poorly worded legislation that blew up on the launchpad.  

Nor do their intellectual justifications hold up. The Bennett Hypothesis that higher federal student financial aid leads to higher tuition has been heavily studied, and evidence for it is mixed at best. Meanwhile, the pronatalist argument that reducing graduate education loan support will boost the birth rate isn’t looking so good, considering the damage likely to be done to the careers of many who deliver babies for a living.  

In one respect, however, the GOP’s gutting support for graduate education has been a success: it helped deliver the votes for nearly $5 trillion in tax breaks to corporations and the wealthy (and massive federal deficits to boot). Tens of millions of nurses, teachers, social workers, and their families are likely to remember that in the midterms. 

The post The GOP War on Nurses appeared first on Washington Monthly.

It happened so quickly you might have missed it. In early September, media outlets across the country reported alarming news for everyone on employer-based health insurance plans.

A national survey of 1,700 businesses that offer health insurance to their workers found that 2026 will bring the steepest increases in their medical costs in 15 years—6.7 percent, on top of a 6 percent rise in 2025. They blame higher hospital and drug prices, greater demand for care, and other factors. According to the consulting firm Mercer, which conducted the survey, much of that burden will be foisted onto employees in the form of higher premiums taken out of their paychecks and higher co-pays and deductibles when hospitalized, seeing a doctor, or filling a prescription.

This pain is hitting at a time when most Americans are struggling financially, and “affordability” is dominating political debate. President Donald Trump’s poll numbers are sinking because voters feel he has betrayed his campaign promise to bring down living costs. Democrats, meanwhile, swept off-year elections by laser-focusing on that vulnerability. 

Yet neither party has managed to come up with a plan to address exploding health care costs for the 165 million Americans with employer-provided insurance. During their failed six-week government shutdown, Democrats in Congress put their political chips on a different health care cost crisis: the expiration of the Obamacare tax credits that Republicans refused to extend in their One Big [Ugly] Bill last summer.

Restoring those tax credits is certainly a worthy fight. More than 7 million Americans face an average 26 percent increase in their premiums in 2026, according to KFF (formerly Kaiser Family Foundation). Some 5 million will likely drop coverage altogether, unraveling much of the gain made since passage of the Affordable Care Act in 2010. Another 8 million will lose Medicaid coverage over the next decade because of cuts to that program in the OBBBA, according to the Congressional Budget Office. As I recently explained in the Washington Monthly, universal coverage is a necessary, though not sufficient, condition for addressing the long-term affordability crisis in health care. 

But in terms of basic political arithmetic, the failure of both parties to offer voters a specific plan for dealing with rising employer-provided health care costs is hard to fathom. After all, 70 percent of working-age Americans get their health insurance from their employers, compared to 10 percent from Medicaid and under 5 percent from Obamacare. (The rest are either uninsured or have military or Medicare disability coverage.)

Employer-provided plans not only cover most working-age Americans and their families, but are also where the health care system’s inflation is worst. Thanks to cost control requirements in the Obama administration’s Affordable Care Act and other government measures, spending per enrollee in Medicare and Medicaid has risen far more slowly over the last 15 years than in employer-sponsored plans. The latter aren’t subject to such controls and are increasingly vulnerable to price gouging by provider and insurer conglomerates that enjoy geographic monopolies. 

The rapid inflation in the prices paid to hospitals, doctors, labs, and other health care providers by employer-sponsored plans also contributes to the slow or stagnant real wage growth that most Americans have experienced for many years. Corporate revenues that might otherwise have gone to raises have instead been spent on the ever-rising costs that employer plans are compelled to absorb. 

For a long time, most workers covered by these plans were only dimly aware of how these rising prices affected their standard of living because they rarely had to reach directly into their own pockets to pay them. But that is becoming less true as employers try to offset the ballooning costs by exposing their employees to ever-higher premiums, deductions, co-pays, and co-insurance. In recent years these out-of-pocket costs have on average been speeding ahead at a rate faster than inflation and workers’ wage gains. 

Just as rising electric bills turned out to be the sleeper concern of voters in the 2025 off-year elections, so might higher employer-provided health care costs in the 2026 midterms. It would be political malpractice if Democrats did not offer the 165 million Americans with employer-provided coverage real relief from costs that are eating away at their paychecks and standard of living.

In what follows, I sketch out the basics of a three-part plan that offers a practical and enduring solution to the health care affordability crisis. 

First, the plan would place a reasonable cap on the percentage of income any individual or family must pay for health care annually, regardless of whether or how they are insured. This will radically reduce the financial toxicity visited on many insured persons when they get sick, and the scourge of new medical debt heaped on the un- and underinsured. 

Second, the plan would require health care providers to charge the same price for the same service, regardless of a patient’s insurance status. This will save the system hundreds of billions of dollars annually by reducing administrative expenses and by bringing down the grossly inflated prices providers charge patients with employer-provided coverage—currently two and a half times what they charge Medicare. 

Finally, the plan would put all hospitals on a budget—a move that would end insurers’ prior authorization schemes and incentivize providers to keep people well and deliver the most effective and efficient care when they get sick.

This three-part reform plan will put the American health care system on a long-term path to controlling overall costs. It will also help employers’ bottom lines and increase the likelihood that more small businesses will be able to offer health insurance to their employees. Best of all, if accompanied by a mandate that employers share a portion of the savings with their employees, it will deliver immediate relief of between $1,500 and $4,000 to the typical working American family—a rebate, if you will, on the excessive health care expenses they have been unwittingly paying. That’s a benefit any self-respecting political candidate ought to be happy to run on.

One bold solution that many left-of-center Democratic candidates competing in next spring’s primaries will likely run on is Medicare for All. But in general elections, that program will run into the same political buzz saw that doomed the effort in Senator Bernie Sanders’s Vermont, the only state that has tried to create a M4A model. Its Democratic governor concluded that the level of taxation necessary to entirely replace employer contributions and reduce individual out-of-pocket expenses was prohibitive. Moreover, a single-payer health care system remains vulnerable to politically charged slogans like “You’ll lose what you have.” Despite the staggering growth in costs, most businesses, unions, and employees want to keep employer-based coverage.

Other Democrats, meanwhile, are already fashioning long lists of health care system changes they hope to enact should they regain Congress and the White House in 2029. Those include curbing provider and insurer consolidation through rigorous application of antitrust law; lowering the Medicare eligibility age to 60; extending the government’s price negotiations to more drugs; prohibiting drug advertising on television; cracking down on pharmacy benefit managers; allowing greater use of physician and nurse assistants; allotting more funding for fighting substance abuse and treating mental health; and more. Few will read this small-bore, incrementalist agenda, and even fewer will understand how it saves them money.

What the Democratic Party and health care reformers need to address directly is affordability, the main issue bedeviling the American people. The reforms needed to achieve affordability must be few in number, easy to understand, and provide real relief. As former Labor Secretary Robert Reich recently noted, people are not persuaded by a “‘10-point plan’ with refundable tax credits that no one understands.”

To that end, I propose that every Democratic candidate looking for a popular, easy-to-sell health care agenda unite around these three simple reforms.

A firm cap on all out-of-pocket expenses

All payers, whether private or public, must restructure their health plans so that no individual or family spends more than 8 percent of their annual income on health care. This cap covers all premiums, co-premiums, deductibles, co-pays, and Medicare payroll taxes and Part B premiums. A hard cap will sharply reduce the number of people accruing new medical debt. The medical debt crisis has left at least 20 million adults with either unpaid bills or long-term debts (some estimates are as high as 36 percent of all U.S. households). This forces millions of people into credit card debt, the arms of predatory lenders, or bankruptcy. It forces them to cut back spending, eliminate “frills” like home repairs and family vacations, and skip payments on other bills. 

A firm cap on out-of-pocket spending will substantially reduce the unseemly sight of Americans, alone in the developed world, launching GoFundMe pages to pay their medical bills. It will also finally make the U.S. health insurance system fair because it spreads the financing of high-cost patients across all plan members without unduly burdening the sick. This is, after all, what insurance is supposed to be about.

All government programs and the individual market under Obamacare will also be governed by this cap. In the latter case, it will replace its current complicated subsidy formula. There is a precedent for this principle: The Biden administration’s enhanced subsidies for exchange-purchased plans included an 8.5 percent cap on individual premiums. 

One price for all

America must adopt a single-pricing system under which each provider charges all payers the same amount for the same service or product. This will sharply lower prices for private plans, which paid on average two and a half times more than Medicare and Medicaid in 2022, according to a Rand survey. This in turn will provide substantial premium relief for both employers and workers.

The U.S. is the only country in the world that has an optional private insurance market for the working-age population with no government-mandated mechanism for controlling prices or premiums. (As noted above, those are slated to rise by nearly 7 percent in 2026.) Multiple payers in that private insurance market create multiple prices that are largely determined by the relative market power of providers and insurers, which have been combining into geographic monopolies that extract ever-higher payments from employers. 

As a result of multiple players each paying different prices, U.S. hospitals and physicians’ offices administer the most confusing and expensive billing systems in the world. Some providers have as many as a dozen different prices for the same service: one for traditional Medicare, one for Medicaid, and one for each insurer in their service territory—each of which negotiates different rates for its different plans, including privately managed Medicare Advantage and Medicaid. Then there’s the rack rate for anyone who walks in off the street.

The cost estimates for administering this complex system range into the hundreds of billions of dollars a year. I estimate that the administrative savings alone from simplified single pricing could save employers and employees at least $100 billion a year in reduced premiums. 

Prices would instead be determined by a process like the one Medicare has used for decades to set the amount doctors and hospitals receive for treating patients with specific conditions (with individual hospitals having some pricing flexibility as long as they charge all patients the same—see next section). In practice, that would mean raising Medicare and Medicaid rates while dropping commercial rates, thereby creating a single-price schedule sufficient to meet the overall financial needs of the system. The exact amount of savings would depend on how much government program prices would have to rise to accommodate the economic needs and political power of providers. But the savings to employers and covered employees would be enormous, likely reducing premiums by hundreds of billions of dollars annually in addition to the $100 billion in administrative savings. 

Another benefit of single pricing is transparency for consumers. Not many medical services are shoppable. No one experiencing what they think is a heart attack rushes to their computer before the ambulance arrives to find out who has the cheapest ER prices. Indeed, a recent study by the Health Care Cost Institute estimated that only 12 percent of 2017 medical expenditures, excluding prescription drugs, were either delayable or discretionary, and thus shoppable.

But greater competition in this limited set of services can help keep prices down. Unfortunately, current transparency laws have proven largely unworkable for consumers hoping to shop around for the cheapest alternative for, say, an MRI scan on that troublesome knee, or a routine colonoscopy. Most providers, given the multiple prices they must post, have created disclosure websites that are about as easy to navigate as a health insurance policy. Requiring every provider to list a single price, especially if linked to the federal government’s existing quality ratings, will foster competition previously unknown in the health care sector.

Put providers on a budget

Serious problems can arise after moving to a single-price system, as Maryland, the only state that has one, discovered over a decade ago. Hospitals there began to game the system by increasing unnecessary surgeries, tests, and procedures.

Maryland’s solution was to require that hospitals and hospital systems, which collect a third of all health care spending, adhere to an annual budget no matter what price they set on individual services. The state’s regulator, the Health Services Cost Review Commission, also sets limits on how much those budgets can grow each year after accounting for changes in demographics, best practices, and technology. Providers are guaranteed their annual budgets. If an individual service is used more or less than anticipated, the price for that service can be adjusted up or down for all patients, but hospitals may not exceed their budgets. 

Requiring providers to adopt these so-called global budgets that grow more slowly than the rest of the economy creates a financial incentive for eliminating wasteful care, and frees up resources to boost primary and preventative care. Hospitals on a budget earn more money if they don’t have to provide as much care for the sick, meaning that they’re incentivized to keep people healthy while generating the best health outcomes at the lowest possible price for their patients when they do get sick. 

These three reforms work best if adopted in tandem. Each cannot succeed on its own. But if adopted together as part of new federal legislation, these reforms could put the U.S. health care system on a glide path to financial sustainability. 

Making them work will require significant federal expenditures. How much, and how to pay for it, is a difficult but solvable question. 

Phillip Longman, senior editor at the Washington Monthly, has long argued for a single-price system that would reduce what self-insured businesses and private insurers pay by 60 percent, matching the prices that Medicare currently pays. If this were possible, no federal funds would be needed to finance a single-price system. Alas, I don’t believe it is possible. 

Though it’s true that many hospitals and physicians serving mostly working-age and Medicare-covered patients are financially stable and offer excellent care, those serving less healthy patients in low-income areas—so-called safety-net hospitals—are frequently on the brink of bankruptcy. Survival for many depends on the additional monies brought in by their relatively few well-insured patients and federal subsidies. It would be a disaster for these providers if rates paid by privately insured patients dropped to current Medicare rates.

Hospitals in well-off areas, meanwhile, feast off the higher payments extracted from their well-insured clientele. That’s where the fat in the system is. But lowering their prices to existing Medicare rates would deliver an immediate financial shock to existing operations, generating tremendous pushback from local hospital leaders, physicians, and their elected representatives, regardless of party. 

To make a single-price system work economically and politically, then, Medicare payment rates to providers will also need to rise. How much? By 60 percent, I would estimate, based on a real-world test case. When Democratic leaders in Washington offered a publicly funded option on that state’s Obamacare exchange, provider organizations successfully lobbied for payment rates that were 160 percent of Medicare rates—still lower than existing commercial rates, but well above the government program’s rates. They convincingly argued that many hospitals and doctors’ offices could not survive without the cross-subsidization provided by the sky-high prices paid by employer-provided plans.

A single-pricing system that made a similar average rate cut for private payers would save employers and their employees, according to my own rough estimate, more than $400 billion a year. That works out to a reduction of $1,200 in annual premiums for the average working family, or a total of $1,500 a year when administrative savings are added in (presuming employers are mandated to share the savings with their employees). 

The problem, of course, is how to finance that extra $400 billion, which will now be coming from the federal government. The obvious fix would be to recapture the $400 billion in employer savings by raising their Medicare taxes by an equal amount (while not raising such taxes on employees). 

Financing single pricing in this way will have the additional benefit of boosting manufacturing in the U.S. by making the health care cost burden between firms more progressive. Old-line firms like General Motors, Caterpillar, and John Deere pay the highest premiums because their workforces are older, sicker, and middle income. Meanwhile, the highly profitable tech titans that now dominate the U.S. economy, like Apple, Meta, and Google, have workers who are younger, healthier, and better paid. They spend far less per worker for health insurance. Tripling the employer Medicare payroll tax will have the beneficial effect of lowering total health care costs for those firms with older, sicker workforces while raising costs for those businesses with younger, healthier ones. 

For this reason, old-line firms with older workers would have good reason to provide crucial political support for the plan. We can also expect, however, well-funded and intense pushback from other corporate sectors that would face sharp payroll tax increases. Their opposition, plus resistance from providers, will make reform a tough road.

But there’s no law saying that the only way to fill the $400 billion gap is by raising Medicare taxes. Other forms of federal revenue would work. Lawmakers could, for instance, tax things that make people less healthy: air pollutants, sugar-laden foods, or other detrimental products. Alternatively, they could pay for the plan by raising tax rates on corporate and top earners—moves that voters overwhelmingly favor. Indeed, much of the plan could be financed merely by closing the insane new loopholes (such as gutting the alternative minimum tax) that the Trump administration is creating for major corporations and wealthy individuals above and beyond the OBBBA. 

This would be a huge net advantage to the vast majority of employers, who would be relieved of a significant share of their health care liabilities with no requirement that they pay higher Medicare payroll taxes. And Democrats could mandate that an appropriate portion of that money be rebated to employees in the form of higher pay. In 2024, the total estimated cost to a typical family of four in an employer-provided health plan was around $27,000, according to KFF. If such a family received a 25 percent share of the savings from these reforms, its pretax income would increase by around $4,000.

To win back working- and middle-class voters who already trust them more than Republicans to do the right thing on health care, Democrats need to offer a plan that immediately limits workers’ out-of-pocket costs. For employers, unions, and others who want to “keep what they have,” single pricing tied to annual budgets preserves the employer-based system while providing them with the long-term benefit of slower-growing costs. For the millions of small businesses that don’t currently provide coverage, the plan will make it much cheaper to do so. Such a plan might even win support from the few GOP officials willing to free themselves from the fear-driven grip of Trump’s faux populism.

The post For Democrats, a New Way to Make Health Care Affordable appeared first on Washington Monthly.

The release of Jeffrey Epstein’s email archives by House Oversight Committee members has quelled the upset in Democratic circles over the shutdown climbdown and returned the focus to what President Donald Trump knew about the late financier’s crimes.  

Whether that focus can be sustained is unclear. The House will soon vote to direct the Justice Department to release more Epstein documents, thanks to a discharge petition that collected its 218th vote after four Republicans broke ranks, and Democratic Representative Adelita Grijalva of Arizona was allowed to take her seat after a 50-day delay imposed by Republicans.  

However, Senate prospects for an Epstein document dump are murky. Senate Majority Leader John Thune is not obligated to schedule a vote and has not promised to do so. Even if it cleared Congress, Trump would almost surely veto it. 

Democrats could try to make Trump’s Epstein stonewalling a midterm election issue, with promises to subpoena documents if they gain control of one or both chambers. After all, overwhelming majorities want the documents released. But focus on Epstein waxes with new developments in the underage sex trafficking case, then subsides as other stories dominate the news cycle.  

Trump, of course, often creates his own news cycles. He has a bottomless capacity to shock.  

But now he has an opportunity to distract by doing something helpful: alleviating the imminent spike in health insurance costs from the expiration of enhanced Affordable Care Act subsidies. 

Politico reports that “White House officials and Republican lawmakers are cognizant” of how health care concerns helped Democrats take the House in the 2018 midterms and “are looking to coalesce around a plan for the future of the health care system.” 

Just as before the 2018 midterms, which were disastrous for the GOP, that plan doesn’t exist, but Republicans are considering their options. Per Politico, “Options that administration officials have publicly teased in recent days include giving money directly to Americans to cover health expenses, and subsidizing out-of-pocket costs for low-income people enrolled in the ACA.” Among congressional Republicans, some “support depositing funds into Health Savings Accounts, which can be used more broadly on expenses and roll over year to year, while others would opt for Flexible Savings Accounts, which expire at the end of the year and are narrower.” NBC News reports Republicans are nowhere near an intra-party consensus on what to support. Significantly, both it and Politico note that Trump has not “ruled out” what Democrats want, a simple extension of the expiring enhanced subsidies.

When it comes to policy, an extension is the best approach to address the disparate impacts of the expiring enhanced subsidies. CNN explains that “More than 90% of [ACA’s 24 million] enrollees are receiving premium assistance, which, for roughly half of policyholders, reduces their monthly cost to $0 or near $0.” Because Democrats during the Biden administration lifted income caps for the enhanced subsidy program, expiration hits middle-income households especially hard. Moreover, the Trump administration has already made the formula for the remaining subsidy stingier. The health policy analysts at KFF estimate the combined impact of the expiring enhanced subsidies and the new subsidy formula means a 45-year-old individual with an annual income of $20,000 would pay $420 more in health insurance premiums for the commonly chosen “Silver Plan,” while a 60-year-old couple earning $85,000 would pay $22,635 more, more than a quarter of their income. 

Trump can be miserly, as evidenced by the administration’s appeal to the Supreme Court to deny SNAP benefits, but he’s not averse to government largesse when he thinks it serves his interests. He is generally reluctant to do whatever Democrats want him to do. Senate Minority Leader Chuck Schumer already offered a mere one-year extension for a proposed deal to end the shutdown—enough to help Republicans take the issue off the table for the midterm elections—which Trump rejected.  

As he considers his options, Trump must contend with the Republican caucus’s self-styled deficit hawks. They proved willing to rack up more debt by supporting the so-called One Big Beautiful Bill in the name of party unity. (Extending the enhanced ACA subsidies would cost about $35 billion a year over 10 years, while the One Big Beautiful Bill will cost about $330 billion a year.) But undoing cuts to the Affordable Care Act may be more than they would swallow. 

The political crosscurrents make a bipartisan health care deal unlikely. Yet Trump could still use the health care issue to distract from the Epstein emails about him knowing about “the girls” and spending hours with one. He could offer a half-baked plan that wouldn’t mitigate the price spikes but could provide political cover and help shift blame to the Democrats.  

In that scenario, the challenge for Democrats will be to keep it simple. They could argue: Democrats would entirely avert the loss of the subsidies, and Republicans would not. No complex details needed.  

Republicans would then find themselves in the unusual position of having to explain the more complex elements of their proposal, without having earned any credibility from the public as genuinely interested in making health care affordable. Quite the opposite, as the One Big Beautiful Bill was hammered for its sharp health care cuts.  

Of course, Trump could always distract with all sorts of insane executive orders, proposals, and comments. But no matter what happens with Epstein or any other Trump act, more than 20 million people will soon get socked with much higher health insurance costs that they are unlikely to forget in November. What’s really in Trump’s interest, and what would really distract from Epstein, is solving the looming insurance premium hikes. However, neither he nor his party has proven capable of crafting any significant health care policies, 16 years after declaring war on the Affordable Care Act, let alone thoughtful ones. 

The post Trump Could Deal With the Epstein Scandal by Addressing Health Care  appeared first on Washington Monthly.

The Trump administration’s wrecking ball has succeeded in shattering one of the core beliefs of centrist health care reformers, which states: Incremental reforms will eventually lead the U.S. to the promised land of health insurance for all—something most advanced industrial nations achieved more than 75 years ago. 

Even many Republicans once signed onto the gradualist approach to achieving the goal of universal coverage. In the early 1970s, President Richard Nixon proposed covering everyone through insurance industry-managed plans. In the 1990s, a Republican-controlled Congress authorized universal coverage for children. Even President Trump in 2017 vowed to replace Obama’s Affordable Care Act with a new plan that would provide “insurance for everyone.” Ultimately, he failed to either release a plan or repeal Obamacare.  

But now, for the first time, the U.S. is making a U-turn on the long road to health care for all, with the GOP not even pretending that universal coverage is a desirable national goal. 

The One Big Ugly (not Beautiful) Bill signed by the president last July will drive an estimated 17 million people from the insurance rolls by 2034, according to KFF. More than two-thirds of those losses will come from cuts to Medicaid. Half those cuts, which establish bureaucratic roadblocks for obtaining coverage, won’t be reversed even if the Democrats succeed in forcing concessions from the majority party during the shutdown negotiations, which are still underway as of this writing.  

Thanks to legislation Democrats passed during Joe Biden’s administration, the national uninsured rate fell last year to 8 percent, which is within hailing distance of universal coverage (generally considered to be 5 percent or less). Some states are already below that threshold, which might have occurred nationally had not 10 Republican-run states, including populous Texas (still 16.4 percent uninsured) and Florida (10.9 percent), refused to expand Medicaid to cover the working poor. That overall rate is certain to rise next year and for the rest of this decade. If no changes are made, it will soar into the mid-teens, nearly to the levels seen before the Affordable Care Act passed in 2010. 

Universal coverage doesn’t guarantee Americans will enjoy better health. Nor does it ensure health care will be affordable. However, it is inconceivable that either of those goals can be achieved without universal coverage, which is a necessary, though not sufficient, condition for addressing the long-term health care cost crisis affecting most American households. 

The incrementalist strategy emerged in the wake of President Harry Truman’s failed attempt after World War II to implement a government-run, universal health insurance plan, similar to those adopted by many European countries. Opposition from the American Medical Association, labor unions with their newly negotiated employer-based plans, and a burgeoning health insurance industry doomed the bill.  

But calls for universal coverage never ceased. A decade-and-a-half later, with the White House and Congress in Democratic hands after Lyndon B. Johnson’s 1964 landslide, the government created Medicare and Medicaid for the old, disabled, and poor. In 1997, after the Bill Clinton administration’s significant push for universal coverage failed, a Republican-led Congress included a separate plan for uninsured children in the Balanced Budget Act. 

Then, in 2010, with Barack Obama in the White House and the country reeling from the Great Recession, a Democratic Congress passed the Affordable Care Act. It created a subsidized individual market for those without employer coverage; expanded Medicaid to include individuals and families earning up to 137 percent of the poverty level; and began experimenting with a host of delivery system reforms to hold down costs. 

However, cost-saving measures cannot be effective unless everyone is in the insurance pool. Uninsured individuals often postpone necessary but non-emergency care. When they become so sick that they must seek care, they show up in emergency rooms, where care is the most expensive, and where their outcomes are usually worse because they waited too long. For their troubles, they are often saddled with unpaid debts. 

The dysfunction wrought by a growing pool of uninsured people affects everyone’s pocketbook. Providers and insurers use the uninsured’s unpaid bills as an excuse to pass along those expenses in the form of higher prices to the privately insured, who already pay 2 ½ times what Medicare recipients pay on average. This results in not just more expensive plans for employers (the median family plan cost a staggering $27,000 in 2025), but higher co-premiums, co-pays, and deductibles for their employees, whose share of the total cost of “employer-financed” care has hovered between 25 and 30 percent for decades. (I put scare quotes around “employer-financed” because employer contributions are a tax-deductible business expense that otherwise would go to workers as wages if it weren’t spent on benefits.) 

Universal coverage doesn’t guarantee that health care will become more affordable for everyone. But it reduces the level of more expensive, uncompensated care in the system, which is necessary to lower prices for everyone, including private insurers and their employer customers. Universal coverage is a crucial prerequisite for achieving more affordable health care.  

Yet now, under Trump and a supine Republican Congress, America is deliberately reducing the ranks of the insured. The process has already begun. Premiums for individual plans being sold on the exchanges for next year are soaring due to the expiration of enhanced subsidies, which will discourage many people from buying plans. 

Though the bill’s new Medicaid work requirements were postponed until after the 2026 mid-term elections to hide their full effects from voters, states were given the green light to begin enforcing twice-annual recertification requirements. Many red states are already moving to do that, as well as cut their Medicaid spending in response to the cutbacks in federal support for the joint federal-state program. Millions of low-wage workers will start losing their Medicaid coverage next year, not because they aren’t working, but because they become frustrated by the paperwork requirements set up by hostile bureaucrats beholden to their Republican overlords. 

Democrats on Capitol Hill are singularly focused on maintaining the enhanced subsidies and restoring the cuts in Medicaid financing. That means the work requirements and other bureaucratic roadblocks will remain because they can’t be addressed in a reconciliation bill. No matter how the shutdown is resolved, a sharp decline in both coverage and access is inevitable. 

That will financially harm almost everyone covered by employer-sponsored plans. This year, those rates soared at twice the inflation rate on average, according to the annual KFF employer survey of just under 1,300 firms. Mercer, a leading benefits consulting firm, says rates will rise by a similar level next year. Plan structures will undoubtedly include higher co-payments, higher deductibles, and higher co-premiums for workers and their families. 

No matter how the government shutdown is resolved, the health care affordability crisis, exacerbated by the historic GOP U-turn on universal coverage, will remain a salient issue during next year’s House and Senate campaigns. The only question is whether Democrats will be able to take advantage by offering a program that addresses voters’ number one concern when it comes to health care. 

The post Republicans Have Stopped Pretending to Care About Health Care appeared first on Washington Monthly.

As the government shutdown enters its fourth week, the impacts are taking their toll on workers nationwide. The shutdown exacerbates the precarious economic situation for millions of Americans impacted by Trump’s capricious tariff regime. The stock market isn’t yet feeling the pinch, but that is partly because it is buoyed by an AI investment frenzy that looks increasingly like a bubble getting ready to pop. 

Most attention has understandably focused on furloughed government workers, the recently unemployed, and the cruel, partisan cuts Donald Trump’s administration is making in blue states and cities. But another class of workers also suffers greatly from these shocks while receiving little attention: the self-employed. For example, self-employed individuals, small business owners, and their employees make up roughly half of all adults covered by Obamacare, premiums for which are set to skyrocket in January thanks to GOP-imposed cuts that are at the center of the shutdown. As they fight to overturn those cuts, Democrats would be wise to present themselves as champions of these entrepreneurial Americans. But will they? 

According to the last U.S. Census, there are over 16 million self-employed Americans, not including an uncounted number of gig workers and sole proprietors on the economy’s periphery. And as Will Norris wrote earlier this year in a superb piece here at the Washington Monthly, American policy choices seriously disadvantage this large and vital sector of the economy. Gig workers, independent contractors, and other self-employed individuals are subject to punishing monopoly predation and tend to lack employer-provided health care, paid vacations, and other benefits that people who work for larger organizations take for granted.  

They also receive little real support from either political party. Rhetorically, the Democrats pay them little public attention (the 2024 Democratic Party platform mentions “workers” 78 times and “union” 23 times, but “self-employed” workers and “independent contractors” just once each). Meanwhile, the GOP offers them only mendacious lip service. Republicans tend to make massive giveaways to wealthy capital under the guise of helping “small businesses” and “entrepreneurs” who are neither small nor truly innovative. 

Democratic campaigns do sometimes outline policy proposals to spur entrepreneurship. The Harris campaign, for instance, listed a series of proposals aimed at helping small businesses thrive through tax deductions, streamlined regulations, increased access to capital, and so on. But these tend to be small-ball measures with little fanfare that, while potentially effective on the margins, also sound cribbed from a traditional conservative playbook. On the flip side, social Democrats and especially Democratic socialists tend not to emphasize small business and entrepreneurship for obvious reasons. After all, these have long been the darlings of the right, a rhetorical wedge used to increase the power of capital at the expense of labor by putting a mom-and-pop face on big business.  

Democrats could change the script here by offering expansive economic policy on everything from healthcare to housing that Republicans typically decry as socialist, while legitimately pointing out that they are working to benefit actual small businesses, solopreneurs, and the self-employed. It is a dirty secret of economic policy that Republicans explicitly champion an agenda that keeps workers not only less able to organize into a union but also chained to their employers and afraid to strike out on their own, lest they lose access to healthcare, retirement, and other benefits. Since two-thirds of start-up businesses typically fail within ten years, a weak social safety net also jeopardizes the ability of the self-employed to house and feed their family unless they’re privileged enough to have a family trust fund. 

The most obvious place this dynamic appears is in health insurance. One of the most critical functions of the Affordable Care Act was to provide more reasonable healthcare options to the self-employed and microbusinesses. The Republican decision to allow tax credits to expire as part of their big budget bill is the central cause of the shutdown, as Democrats (and even Marjorie Taylor Green!) rightly see it as reckless and inhumane. But Democratic rhetoric on the issue usually—and for good reason—focuses primarily on the most marginalized communities facing disaster, including rural areas typically supportive of Trump. But there is also a wide-open lane here to appeal to around 20 million precarious self-employed Americans paralyzed about what their health insurance options will look like next year, and to do so in a way that could sound equal parts Bernie Sanders and Ronald Reagan. Americans don’t love big business, but they do love hardscrabble microbusiness owners trying to turn a dream into a decent living. 

Trump’s crippling tariffs are perhaps the second most crucial place where Democrats could gain an advantage from a greater emphasis on the self-employed. Consumers feel the pinch from higher prices, and big businesses are hobbled by uncertainty. But microbusinesses and boutiques that rely on low-margin imports are being devastated. Everyone from Etsy sellers to specialized grocers feels the crushing burden of low profit margins flipped upside down by tariffs. And while big businesses can typically wait out uncertainty, many small suppliers and contractors downstream of them are going under as those larger entities put everything on hold, from research and development to distribution. 

The emerging partnership between Trump and corporate oligarchs presents another opportunity for Democrats to stand with small-scale entrepreneurs. The millions of independent merchants who peddle their wares on Amazon have watched in fury as the monopoly platform has raised its share of sales revenue per item from a third in 2016 to 50 percent in 2022, plus additional fees since. Uber drivers have seen that the company increase its take by similar amounts. As Americans have moved from cash to credit cards since the pandemic, small merchants are being eaten alive by high “swipe fees” imposed by the Visa/Mastercard duopoly. By calling for antitrust and other measures to curb this monopoly rent-seeking, Democrats could earn significant goodwill from this suffering class of small entrepreneurs. 

In states and districts where even populist traditional left-liberal rhetoric falls flat, much of the larger agenda of social democracy can be reframed as an engine of real small business and employees without an HR department. More generous social security and pensions are available for those who don’t have the luxury of a large corporate 401(k). Skills training and lower-cost college would allow people who want to pursue their dreams to leave foul and abusive jobs. Subsidized childcare and pre-k make it possible for regular people to be good parents while opening that time-intensive restaurant. And so on. 

Finally, as AI slashes entire professions across the economy and sits on a potentially precarious bubble, even more Americans are likely to try to find independent ways to make ends meet. Conservatives have no answers for them, and Democrats have all too often spoken to the ranks for the current and future self-employed either in the paternalistic language of equity or the arcane white-paper-speak of tax rebates and loan programs. 

There is a better way, a clear policy need, and millions of underserved voters up for grabs. 

The post Government Shutdown Fallout: A Reminder That We Still Need Health Care for Gig Workers, Sole Proprietors  appeared first on Washington Monthly.

Robert F. Kennedy Jr.’s Make America Healthy Again (MAHA) commission on children’s health reached its ignominious conclusion Tuesday by issuing a final report that failed to mention the biggest threats to childhood ill-health in the U.S.

The final 73-page report, which was accompanied by a 20-page strategy memo, made no mention of:

• Gun violence, the number one killer of American children under 18;
• Smoking, a lifelong habit most take up when teenagers; or
• Global warming, the greatest long-term threat facing the youngest generation.

Mentioning these issues would have required the report call attention to the biggest roadblocks standing in the way of addressing each of these issues. They are, respectively, the Gun Lobby, Big Tobacco and Big Oil & Gas.

Those industries are fervent supporters of the U.S.’s authoritarian headman, Donald Trump. His only consistent political position—one that he requires all his lackeys adhere to—is steadfast support for the nation’s richest and most powerful corporations and individuals, especially those that have given him huge campaign contributions.

Even when it came to addressing the issues that Kennedy claims to care most about, his need to please Trump by giving special interests a pass denuded the final report of any meaningful measures. Those issues include the prevalence of ultra-processed food; chemical food additives; environmental toxins; and excessive use of psychotropic drugs and vaccines. Other than vaccines (last week, his denigration of vaccines led even a few Republican physician-Senators to question his honesty), those are issues that most Americans and unbiased researchers would also like to see addressed.

Yet the final report failed to outline any concrete steps that the Health and Human Services Department, the Agriculture Department or the Environmental Protection Agency plan to take. “A lot of this is nice (but) it’s a report about intentions, not about actions,” New York University professor of nutrition emeritus Marion Nestle told the PBS NewsHour. “How on earth are they going to do these things (when) the word regulation is only mentioned once?”

Regime actions contradict recommendations

Many of the deregulatory and budget cutting actions taken by the Trump regime since taking office work directly against the goals outlined in the report. For instance, the Environmental Protection Agency’s research department has been gutted, all but eliminating the agency’s ability to scientifically determine which environmental toxins are causing significant harm to children’s health.

The budget for the Supplemental Nutrition Assistance Program (colloquially food stamps) has been cut sharply, which will reduce food assistance to almost three million children. Rather than taking steps at the federal level to limit the ability of low-income beneficiaries to purchase sugar-laden beverages or salt-heavy snack foods (instead, they plan to offer technical assistance to states that want to do that), the Trump regime is making more children go hungry. Common sense suggests allowing three million kids to go hungry will destroy the health of far more children than allowing parents of kids on food stamps to continue buying soda pop.

The strategy report called on the Department of Education to “help states” reinstitute the presidential fitness test. The DoE is currently being dismantled by the Trump regime.

Also, it claimed HHS’ Administration for Children and Families will “promote greater physical activity” in after-school and summer programs. Meanwhile, Trump’s budget cutters slashed $7 billion to support those programs in June, only to restore a mere $1 billion a month later after widespread protests from educators in both Red and Blue states.

Perhaps the most curious oversight in yesterday’s strategy report was its turnaround on the chemicals, dyes and other additives in ultra-processed foods (UPFs), a major bête noire for Kennedy and a long-time concern of mainstream nutritionists. The main report’s 7-page section on UPFs contained 75 footnotes. Yet the strategy memo contained just a single action item of little significance: “USDA, HHS, and FDA will continue efforts to develop a U.S. government-wide definition for ‘Ultra-processed Food’ to support potential future research and policy activity.”

“What this says to me is that the first report was written by MAHA,” Jerold Mande, an adjunct professor of nutrition at the Harvard T.H. Chan School of Public Health and a former senior policy official for nutrition in the Bush, Clinton, and Obama administrations, told Time Magazine. “The second one, the White House let industry lobbyists write it.”

The post RFK Jr.’s MAHA Movement: Industry Takes Control appeared first on Washington Monthly.

Donald Trump’s policies have caused and will continue to cause large-scale death. According to Dr. Brooke Nichols, a professor at Boston University School of Public Health who oversees a running impact tracker, the destruction of USAID and the various food and medical aid programs under its umbrella has already caused nearly half a million preventable deaths in the developing world. Trump’s destruction extends to domestic operations. In just seven months, he and Health and Human Services Secretary Robert F. Kennedy Jr. have significantly weakened the country’s public health system, moved to cut medical research at universities nationwide, and promised to cut Medicaid substantially. 

One of the leaders fighting to protect public health in the Trump era is the National Medical Association, the largest and oldest organization representing Black doctors and their patients in the U.S. On July 22, the NMA inducted Dr. Roger Mitchell as its new president. Mitchell is board-certified in anatomic and forensic pathology by the American Board of Pathology. He is also a tenured professor of pathology and serves as chief medical officer for the faculty practice at Howard University, his alma mater. He is the co-author of Death in Custody: How America Ignores the Truth and What We Can Do About It, a study of preventable deaths in jails and prisons. 

I recently spoke with Mitchell on the phone about the Trump regime’s attack on public health, higher education, and DEI. This interview has been lightly edited for clarity and brevity.

DM: In your position as a forensic pathologist, a medical doctor, and president of the National Medical Association, how do you assess Trump’s war on public health, especially how Robert F. Kennedy, Jr. is executing it through the Department of Health and Human Services?

RM: One of the things we prioritize at the National Medical Association is evidence-based care, whether that relates to the care of an individual patient or the larger community, which we define as “public health.” Medicine is a science. Therefore, it needs to be science-based. However, what we’re finding is that the decisions being made by the Trump administration—not properly collecting data, putting expertise on the back burner, the response to the measles outbreak, and the undermining of vaccinations, neglecting the need for Medicaid coverage and supplemental insurance for the disinherited—these are not evidence-based decisions. They are political decisions.

You say it is a “war.” I used similar language in my inauguration speech when I was installed as the 126^th president. I noted that physicians have a red cross on our helmets. Our job is to serve and fight for those on the battlefield. The war waged on public health is intentional and will lead to many deaths in communities across the United States.

DM: If the administration isn’t making decisions based on evidence, what are their criteria, as far as you can tell? Who is most at risk due to what you call their “intentional war on public health”?

RM: The most endangered are the most in need. Those individuals who currently need Medicaid are not going to seek care when disease and injury are preventable, but will only seek care when disease and injury are inevitable. Inaccessibility to preventive care leads to higher morbidity and mortality. Then, those who take the opinion of political officials without a medical background, who do not give evidence-based advice, place themselves at higher risk and are also in danger. We see that with those who refuse vaccinations and even refuse to vaccinate their children.

Those without access are the most vulnerable, and when I say “access,” I mean it in the W.E.B. DuBois sense of access as education, economics, housing, and environmental justice. Those who suffer from disparities in access are most at risk. But this is not a risk that only affects poor folks. It is going to affect all Americans. That is how public health works.

I cannot read the minds of those making these decisions, but as an outsider, I can only suggest that the decisions are based upon how to enrich a small few. Let me give you the evidence for that conclusion. As a public health official and someone who has worked in medicine for two decades, I know that healthcare’s finances have ballooned. There is no way in the world that we can allow the cost of health care to continue on this trajectory. Value-based care, promoting prevention, and rewarding providers, medical care associations, federally qualified hospitals, and patients for engaging in necessary education and practice for prevention—that is the work that decreases the cost of health care. What decreases the cost of health care is more healthy people. Healthier people will need expensive care less frequently. So, when you remove people from having access to prevention and the care to treat disease and injury, individuals will choose to eat, take care of their families, and pay their mortgage. They will let disease and injury fester in a way that they need care later, and that care is more expensive. So, the care that is going to be delivered in this country if the Republican plans continue will increase costs and decrease life expectancy.

DM: Another battleground is higher education. You are also a professor at Howard University, your alma mater. What are the dangers of Trump’s assault on higher education?

RM: I come from a middle-class family. My family wasn’t poor—a college-educated mother, a father who was a businessman. When I went to medical school, my loans were about $180,000. That was more than tuition, but I had to take the loans out because I had to live. I could not work in medical school. I tried. I was an FBI forensic scientist. I was trained as an evidence technician, planning to work in the local field office while attending medical school. That lasted two weeks. There was no way that I could work and study as much as one needs to study to do well in medical school. I lived in a very small apartment above a barber shop. Rent was $400 a month. You can imagine what type of accommodations I had for $400. Today, graduate education loans are capped at $100,000. If that rule had been in place before, I couldn’t be a doctor today—not because I wasn’t qualified, nor even because I couldn’t pay for medical school. I’ve paid the loans back.

So, those who can’t pay the balance above $100,000 to go to medical school will not be able to go to medical school. Poor people, first-generation wealth, and blue-collar people cannot afford to send their children to medical school, even if those children have 4.0 [grade-point averages] and the potential to become excellent physicians. I’m worried about limiting poor and working-class people’s ability to go to medical school, not only because it will adversely affect those students, but also entire communities. There is already a physician shortage in this country, and there are already disparities for those in the medical field willing to take care of the disenfranchised. Now, we’re going to make it worse.

DM: To continue the metaphor, Diversity, Equity, and Inclusion (DEI) is the third battlefield of the war. Of course, “DEI” can mean anything with the current crew. Same question: How does the attack on DEI threaten America?

RM: If you were to ask any Fortune 500 CEO, they would tell you that diversity of experience, thought, and background is good for the bottom line. It makes economic sense to have a diverse workforce. Even if there is no moral impulse for diversity, the argument that it makes better financial sense should resonate.

We know that in health care, you have better outcomes in communities when those communities have a shared background, which leads to trust with physicians. That is why it is important for the National Medical Association to stand up and say that diversity, equity, and inclusion are paramount. The requirements of the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education for diversity in recruitment and retention were important not only for medical students and residents, but also for the outcomes of patients positively affected by a diverse workforce. With those requirements no longer being enforced, we risk patients being unable to get quality health care. We have providers and medical students who don’t have the same cultural experience with their diverse colleagues. Everyone becomes better after having proximity to those who are different. At its core, medicine is an empathetic art. Empathy is a huge component of health care—medical practice, nursing, and physical therapy. You name it.

If you don’t have that proximity but later have to provide care for those who are different, where will you get your emotional quotient? That EQ has to be built in.

Degrading DEI standards will increase disease and injury in communities that differ from the majority.

DM: What are some ways the NMA works to counter this, and what do you hope to achieve with your leadership?

RM: We’re ensuring that our residents are supported. Many times, we have found that Black residents have been targeted and removed from residency without justice. We’re working with the Young Doctors Project, which takes young men from urban settings during the eighth grade and mentors them through high school, college, and medical school. We’ve partnered with Elevate MeD, which helps medical students get into residencies. We have another partner, Nth Dimensions, which allows medical students to move into orthopedic programs, where there is a paucity of diversity. We work closely with the Student National Medical Association. We have a strong post-graduate section within the National Medical Association.

We support ourselves as we become entrepreneurs within medicine or move into academia.

We also focus on health justice, violence prevention, environmental justice—and climate change, because drinking clean water and breathing clean air are essential to good health outcomes.

We are also an advocacy organization. The NMA was at the table 60 years ago when Medicaid was written into law, and other medical associations did not favor it. We advocate for equity in health care delivery, no matter where you are from, the money you have, or whether you are rural or urban.

This year’s theme is “Mobilizing Health Justice for a New America.” The days of standing around and talking are gone. We need to start fighting and moving.

DM: Given the high stakes, are you advocating for health care professionals, especially your members, to raise their voices and contribute more to the ongoing debate?

RM: One hundred percent. I’m traveling the country and willing to visit any city, bringing the members of the National Medical Association to the debate, to discuss what needs to happen locally and nationally. I was just in Cincinnati. I was just in Tunica, Mississippi. The NMA just had our annual convention in Chicago.

My grandfather was one of the first Black physicians in Atlantic City. He graduated from med school in 1932, started his practice in 1935, and used to take pies and cakes for payment from those who couldn’t afford care. So, I ask our members to determine how much free health care they can give in their practice. Then, let’s create a national clinical collaborative that provides free health care to communities. Then, let’s use that to pressure the corporate world to pay for medical equipment, the nursing staff, and the technicians. We need to do that if the government doesn’t step up. Health care is a human right.

The post Fighting to Protect Public Health in the Trump Era appeared first on Washington Monthly.

You would think protecting veterans’ access to health care would be sacrosanct in the current political environment.

So how can we explain the Trump regime wielding a budget axe at the Veterans Health Administration? The agency—the largest health care system in America—is in the process of eliminating 30,000 jobs for physicians, nurses and other personnel. That’s nearly one of every 12 employees at the VHA, which is responsible for delivering health care to over nine million veterans.

In recent weeks, Veterans Affairs Secretary Doug Collins, a former Georgia Congressman and military chaplain, cancelled every union contract with the VHA’s physicians, nurses and other employees. This came after the Baptist minister-turned-politician sent letters to VHA workers encouraging them to either retire or look elsewhere for work. Morale at the agency is plummeting.

These were only the first steps in the Trump regime’s plan to dramatically downsize the VHA during his second term in office. The 2026 budget he sent to Capitol Hill called for spending more than a third of the VHA’s $115 billion budget on outside physicians and other private providers. That’s a nearly 50% increase over previous outsourcing, a move that some progressive Democrats in Congress are calling the stealth privatization of the VHA.

“They want every employee to be pushed out so they can decimate the VA’s workforce,” Rep. Delia Ramirez (D-IL) said during a July House Veterans Affairs committee meeting. It “wants them to leave” as part of its plan to privatize services.

The Trump regime’s escalation of VHA privatization extends a decade-long trend. It began in 2014 after a Phoenix VHA administrator was accused of under-reporting appointment wait-times in the reports sent to Washington. (No other health care system reports wait-times. If they did, the VHA would probably look good by comparison.)

Ensuing demands that veterans be allowed to access private-sector providers led to passage of the 2014 Choice Act, signed into law by President Barack Obama. The law launched pilot projects in rural and under-served areas that, while allowing for outsourcing, limited it to situations where the local VHA facility was more than a 30-minute drive from the veteran’s home, or, the facility could not schedule an appointment within 20 days for primary or mental health care or within 28 days for specialty care.

The program became system-wide with passage of the 2018 Mission Act, which also had bipartisan support. Though touted as a major benefit for the 25% of veterans who live in rural areas, the bill broadened the criteria to include instances where veterans and their VHA physicians thought it was in “their best medical interest.” But they needed a second opinion to that effect. Earlier this year, VA Secretary Collins removed the second opinion requirement.

No choices

But is “choice” helping rural veterans? Earlier this month, The American Prospect reported on a comprehensive survey by the Veterans Healthcare Policy Institute that questioned private providers’ ability to serve the needs of the 2.8 million rural veterans enrolled in the VHA. The “analysis reveals a system that cannot provide even basic medical and mental health services to non-veteran patients,” Suzanne Gordon, co-founder of VHPI wrote. “Hundreds of hospitals in America’s rural counties and under-served areas have curtailed critical services or closed entirely. And thousands of counties across America are experiencing significant health provider shortages.”

Things are likely to get a lot worse over the next several years as millions of rural residents on Medicaid or Affordable Care Act insurance plans lose coverage due to the cutbacks recently signed into law. “President Trump, VA Secretary Collins, and Republicans in Congress want to send more veteran patients into an already troubled private-sector system, while depleting that system of the resources necessary to absorb this extra load,” Gordon wrote. “The idea that this will work well is shaped more by ideology than reality.”

If helping rural veterans is the goal, a far more fruitful approach would be shifting VHA resources into the areas where most veterans now live. The system rapidly expanded during the quarter century after World War II to serve the needs of veterans who, for the most part, hailed from urban areas. The system’s 170 hospitals are located mostly in large and medium-sized metropolitan areas.

The VHA also staffs almost 1,200 outpatient facilities. Unfortunately, most rural areas remain poorly served by these clinics. Many rural counties have none. This should come as no surprise. Residents of these areas often have to drive an hour or more to access pharmacies, grocery stores and other retail outlets. Accessing medical services, whether public or private, often involves even longer drives.

Moreover, rural hospitals, which would be a logical place for providing additional services for veterans, are also dying. There simply aren’t enough patients in sparsely populated areas to support comprehensive medical services. The idea that the private sector can meet the special needs of veterans, who suffer disproportionately from chronic diseases, whether related to their service (Agent Orange and burn pit exposure; PTSD and other mental conditions) or not, is absurd.

Here’s an idea. Why not use the VHA budget to establish clinical capacity in these regions? Indeed, they could open their doors to the entire local population, turning the VHA in rural America into the equivalent of a federally qualified health center. This could provide the agency with an additional source of revenue to the extent other payers (Medicare, Medicaid, private insurance) offered coverage to people living in these sparsely populated areas.

Best care

But, you’re probably asking, wouldn’t this take money away from the urban medical centers that are the backbone of the VHA system? These large complexes are currently underutilized, spatially mismatched to where current and future generations of veterans live, and often in need of renovation—a set of circumstances documented by numerous commissions and reports. (See here and here, for instance.)

To help solve these problems, one idea I found intriguing while doing research for this article (it comes from the right-leaning Manhattan Institute) would be to allow the VHA’s urban hospital systems to provide services to people covered by public programs like Medicare and Medicaid and the privately insured.

The VHA model for delivering care is everything a wannabe reformer like myself dreams about (as Phil Longman documented in his 2012 book, “Best Care Anywhere: Why VA Healthcare Would Work Better for Everyone.”). Its physicians are salaried; they are mission-driven (they work for less than their private sector counterparts); they are trained to follow clinical practice guidelines; and, as a general rule, they deliver high quality care (studies have repeatedly documented how VHA outcomes equal or surpass those of comparable facilities). The VHA also provides comprehensive coordinated care for people who require it (including addressing housing and food insecurity and other social issues) and pays the lowest price for drugs.

Unfortunately, its facilities are disproportionately located in regions that no longer house many veterans. Manhattan Institute senior fellow Chris Pope summed up the problem in his recent proposal, “Making Use of VA Hospital Overcapacity: Expand Access to Reduce Costs”:

“The VA operates essentially the same hospitals in the same locations as it did in the 1970s, despite a great shift of the veteran population to the Sunbelt. In 1970, far fewer civilian veterans lived in Arizona (0.2 million) than in New York (2.4 million). By 2020, the number in Arizona had surged (to 0.5 million), while that in New York had plummeted (to 0.6 million). While the VA still operates twice as many hospitals in New York as in Arizona, facilities in the Grand Canyon State have been strained. The VA has substantial excess capacity across the country as a whole; but in a few areas, clinicians have been overworked while patients face long waiting times.

His proposal?

“VA hospitals should be permitted to treat and bill Americans covered by other insurance plans (privately financed, Medicare Advantage, or Medicaid managed care), regardless of their eligibility for VA-financed care. Congress has repeatedly demonstrated that it is unwilling to cut funding for existing VA hospitals, as this may threaten their continued operations. Policymakers should therefore attempt to make better use of these facilities, so that their fixed costs can be spread over more patients.”

Since many veterans who receive free care at VHA facilities are also enrolled in taxpayer-financed private plans like Medicare Advantage and Medicaid managed care, it would also save the government money. “This proposal would provide increased revenues to allow the continued maintenance of VA institutions, without increasing federal expenditures per patient as the veteran population continues to decline,” he wrote. “It would also end the double payment for veterans receiving care through the VA who are also enrolled in Medicare Advantage or Medicaid managed care.”

This seems like an idea well worth exploring—one that has the potential to generate bipartisan support on Capitol Hill.

The post Why Stealth Privatization of Veterans’ Care Is Doomed to Fail appeared first on Washington Monthly.

The woes of organized labor aren’t new to us. One of us (Steve) spent many years as a labor representative in the telecom industry, which has been downsizing its unionized workforce for 40 years, often issuing corporate announcements of significant pending “reductions in force” (RIF). When that RIF alarm bell goes off, the Communications Workers of America (CWA) and the International Brotherhood of Electrical Workers (IBEW) have repeatedly mobilized against looming cuts.

Through workplace mobilization, outreach to labor, community, and political allies, and direct negotiations with telecoms like Verizon or AT&T, these unions have often averted layoffs by securing early retirement incentives.

Are buyouts and early retirement offers cause for celebration or a reminder that management still wants to put heads on the chopping block?

That’s the question facing Department of Veterans Affairs (VA) employees after getting a modicum of good news from VA Secretary Doug Collins. Four months ago, a leaked memo revealed that Donald Trump’s administration wanted to shed 83,000 VA workers this year.

That downsizing of an agency that began the year with 484,000 employees triggered protests nationwide—by veterans’ organizations, VA unions, and patients and their families. Collins stonewalled critics and presided over VA contract cancellations demanded by President Trump’s Department of Government Efficiency (DOGE), which produced few savings. The former U.S. House member from Georgia denied that DOGE-driven job cuts might hurt care for nine million VA patients.

Headed in The Right Direction?

On July 7, Collins took a different stance, announcing that a 15 percent reduction in his agency’s workforce is no longer necessary since 17,000 VA employees have already left, and another 13,000 will do so by September due to “normal attrition” or the lure of early retirement or severance payments.

“A departmentwide R.I.F. is off the table,” Collins said. “As a result of our efforts, VA is headed in the right direction—both in terms of staff levels and customer service.”

However, a far better indicator of where the VA is headed can be found in Collins’ more consistent—but equally misleading—messaging about “making it even easier for veterans to get their health care when and where it’s most convenient for them.”

In the VA Secretary’s view, this means letting eligible veterans choose between highly qualified VA caregivers and referrals to a nationwide network of 1.7 million private-sector providers, whose performance has sometimes been inferior.

Collins’s proposed discretionary budget for FY 2026 favors the latter; it calls for a $14.4 billion increase in federal spending on outsourced care, a 67 percent hike from last year, and an unprecedented 17 percent reduction in funding for VA direct care. In addition, sources report that Collins also seeks Congressional approval to transfer $1.8 billion from the VA’s clinical care budget to boost spending on non-VA providers during the current fiscal year.

This ongoing defunding of direct care will eventually result in more staff reductions and facility closings.

Popular opposition to the threat of both under the Biden Administration helped derail a poorly conceived White House plan to review VA “assets and infrastructure” three years ago. But then Biden’s

VA Secretary Denis McDonough never used his rule-making authority to shore up financing of VA direct care by curbing costly and unnecessary patient referrals to private doctors and hospitals. So, under the second Trump administration, Collins picked up where McDonough, a chief of staff to Barack Obama, left off.

A Divided Reaction

Veteran advocates and other stakeholders in caring for the nation’s eighteen million veterans cheered Collins’s July 7 walk back to varying degrees.

While noting that “30,000 job cuts, even through attrition, risks degrading services, “American Federation of Government Employees (AFGE) President Everett Kelley called this lesser blow ‘a major victory.’” He urged other federal department heads “to follow Secretary Collins’ lead” and abandon their DOGE-driven RIF plans.

Kelley also pledged that, “if the administration continues down the path of privatization, mass layoffs, and unlawful reorganizations, they will hear from us again.”

The million-member Disabled American Veterans (DAV) declared itself “cautiously optimistic” about Collins’s action. The Iraq and Afghanistan Veterans of America (IAVA) hailed it as “a notable and encouraging departure from the previously discussed, much larger cuts.” In their statements, unlike AFGE’s, neither group mentioned ongoing privatization spurred by the VA MISSION Act of 2018. DAV, IAVA and other veterans service organizations favored its passage via a bipartisan vote that handed President Trump one of his biggest first-term legislative victories.

Other veterans’ groups, like Common Defense and VoteVets, remain far more critical of Collins. Common Defense national organizer Joanna Sweatt, a Marine veteran, “warned that Trump’s attacks on VA healthcare haven’t stopped.” On behalf of VoteVets, retired Army Major General Paul Eaton predicted, accurately, that the White House still plans to “demonize, downsize, and privatize VA care.”

As Robert Anderson, a Veterans for Peace member and VA patient in New Mexico, told the Washington Monthly, “the decade-long diversion of funds from the VA for privatization continues at breakneck speed… As a result of cutbacks and shortages, I hear some vets complaining that the VA can’t do anything right. And proving that to be true has always been the goal of the Republican jihad against ‘government-run’ healthcare.”

Russell Lemle, former chief psychologist for the San Francisco VA healthcare and co-founder of the Veterans Healthcare Policy Institute, praised the grassroots organizing and lobbying that resulted in fewer jobs being cut this year. “But the focus on the number 83,000 was always problematic,” he points out. “It set the stage for Collins to scale back his plans and, in the process, appear more reasonable and flexible than he actually is.”

A Roller Coaster Ride

A VA local union activist, who wished to remain anonymous to avoid management retaliation, agreed that “announcing big cuts and then implementing smaller ones results in everyone breathing a sigh of relief when we can’t afford to let our guard down.”

Lemle argues that staff reductions through steady attrition will still hurt the nation’s largest public healthcare system. “When backfilling a vacated position is slowed to a crawl or indefinitely suspended or, worse yet, a position gets removed from the organizational chart, you end up not having enough staff to serve veterans’ needs, which is a recipe for outsourcing more care to the private sector.”

The roller coaster ride that VA workers have been on since Trump moved back into the White House in January has left tens of thousands of talented, skilled, and committed healthcare professionals and support staffers wondering whether they have any future at the VA. “The administration’s message is look for a job elsewhere,” one former VA medical center director told the Washington Monthly.

VA defenders’ organizational challenge is maintaining morale in their ranks, while building on recent protest activity that attracted many previously unengaged veterans.

Saving the VA requires further resistance to Collins’s performative campaign against “waste, fraud, and abuse,” and the GOP’s longstanding goal of restructuring veterans’ healthcare delivery, via incremental privatization. Doing so will be an inspiration to other federal departments and their stakeholders. So no one is better positioned to display red state resistance to Project 2025—and broader disillusionment with Trump—than military veterans, their families, and the federal workers who support them.

The post VA Secretary Says No Department Wide RIFs, But It’s No Time to Cheer appeared first on Washington Monthly.

Seven years ago, Congress passed the VA MISSION Act with the explicit intention that veterans receive the highest-quality healthcare, whether from the Department of Veterans Affairs (VA) or the newly created Veterans Community Care Program (VCCP)—the option to see private providers outside the VA. The legislation’s emphasis on quality was unmistakable; the word appeared 50 times throughout the bill.

In particular, the 2018 legislation requires that VCCP mental health providers are trained in a manner comparable to the VA’s, particularly in clinical areas where the VA has “special expertise” (emphasis added). These specialized areas include, among others, post-traumatic stress disorder, military sexual trauma-related conditions, and traumatic brain injuries. Under this framework, VCCP providers are expected to complete mandatory training in scientifically recommended treatments before providing care to referred veterans.

But a harmful pattern of VA and congressional neglect has emerged, endangering veterans’ lives and threatening the quality that the MISSION Act aimed to protect.

A System Built to Fail

The authors of the MISSION Act understood that the training gap between VA and private sector mental health providers is wide. VCCP mental health providers generally have fewer years of graduate training than VA ones. Compared to the VA, VCCP providers are also far less likely than their VA counterparts to use—or even offer as an option—a scientifically supported psychotherapy for conditions like post-traumatic stress disorder (PTSD), depression, and other mental health conditions. A RAND Corporation study found that “a psychotherapist selected from the community is unlikely to have the skills necessary to deliver high-quality mental health care to service members or veterans.” 

VA providers are required to conduct annual screenings for suicide, PTSD, substance use, military sexual trauma, and depression—mandated protocols that don’t exist in the privatized VCCP. Meanwhile, 57 percent of private mental health providers do not routinely screen for problems common among veterans, such as mental health and substance use issues or sleep-related problems.

To potentially help VCCP providers deliver better care, the VA developed eight comprehensive trainings that address veterans’ urgent mental health challenges—such as post-traumatic stress, suicide prevention, and opioid abuse—each about an hour long. The VA required its own providers to complete all modules, but VCCP’s private providers only need to take the opioid safety module. The remaining seven essential trainings were merely “recommended.” 

The Predictable Catastrophe

The VA’s decision to make critical trainings voluntary for VCCP providers has proven disastrous. A recent Government Accountability Office (GAO) report reveals that between 2021 and 2023, veterans received mental health referrals to 22,725 providers outside the VA. Of those clinicians, only 380—roughly 2 percent—completed a single training.

These failures are alarming, particularly when it comes to specific veteran subpopulations. During this period, more than 8,000 veterans flagged as active suicide risks were referred to providers who lacked any documented training in suicide prevention. While anxiety and stress-related disorders represented nearly half of patients’ diagnoses, barely any community providers had taken PTSD or military sexual trauma training.

Willful Blindness

Perhaps most troubling is that these lax standards for private providers didn’t happen in the dark. The GAO investigators discussed the training deficiencies with the VA, as the Office of Inspector General had previously. The VA said it prioritized “network adequacy”—having enough providers—over enforcing training standards. In other words, a glut of untrained providers is preferable to a smaller pool of well-trained ones. This aligns with Congress’s decade-long push—and this administration’s goal—to further privatize veterans’ mental (and physical) healthcare.

The problem is getting worse. Last week, the House Committee on Veterans’ Affairs (HVAC) advanced the Veterans’ ACCESS Act, allowing veterans to access mental health care in the community “without pre-authorization or referral.” While that may sound like it eases some bureaucratic roadblock, this legislation opens the gates to private-sector mental health clinicians who are undertrained to treat veterans.

Meanwhile, the No Wrong Door for Veterans Act, which the House Committee on Veterans’ Affairs just passed, and the nearly identical HOPE for Heroes Act, which passed the Senate Committee on Veterans’ Affairs, would also increase referrals to non-VA mental health providers. These bills similarly include no training mandates.

A Clear Path Forward

The training standards that govern VA mental health providers should apply to their private sector counterparts. Several key reforms can make it a reality.

First, enforce uniform training standards. All eight core training modules should be mandatory for any provider treating veterans in the VA or community settings. This is a low bar, but better than none.

Second, toughen accountability. Third-party administrators overseeing the VCCP should suspend private providers who fail to meet standards, without exception.

Third, demand transparency. The VA’s Provider Profile Management System (which functions as the main database of community providers used by VA medical center staff to schedule referrals) should display training records and be accessible to both veterans and the public. 

A Moral Reckoning

Representative. Sheila Cherfilus-McCormick, a Florida Democrat, introduced a bill during the HVAC hearing on the ACCESS Act in July, requiring community mental health providers treating veterans to meet the same rigorous training standards as VA clinicians. Committee Republicans immediately voted it down, yet the need only grew stronger this week when the VA announced that veterans are now allowed 52 weeks of mental health services in the VCCP before having to obtain VA reauthorization.

Congress and the VA can no longer ignore care quality—enforceable training requirements must be part of community care legislation. Anything less breaks the sacred trust between our nation and those who defend it.

The post Private Veterans’ Health Care Providers Skirt Tougher Standards appeared first on Washington Monthly.